A case of ruptured distal aortic arch aneurysm with bronchiolitis obliterans organizing pneumonia

We report a case of histologically proved bronchiolitis obliterans organizing pneumonia (BOOP) associated with ruptured distal aortic arch aneurysm (DAAA) into the lung. A 63-years-old male with preoperative episode of hemosputum and hemoptysis was diagnosed DAAA. Preoperative computed tomographic scanning demonstrated that the aneurysm was surrounded with the structure of 2 layers of the enhanced high density external layer and the not enhanced low density internal layer. Combined resection of the left upper lobe and the aneurysm was performed safely because of marked adhesion between the lung and the aneurysm. Postoperative histological examination revealed that the perianeurysmal structure was due to BOOP.     

Total arch replacement for a distal aortic arch aneurysm with right aortic arch

Right-sided aortic arch accompanied by an aberrant origin of the left subclavian artery is rare and seen in 0.05% approximately 0.1% of the population. A 73-year-old woman with this anomaly was admitted to our institution because of the enlargement of the distal aortic arch aneurysm. She also had mild dysphagia. The size of the aneurysm was 70 mm in diameter and she underwent total arch replacement using selective cerebral perfusion through a median sternotomy. Additional right thoracotomy was not required and four cervical vessels were reconstructed. The postoperative course was uneventful. This case report shows median sternotomy alone may provide sufficient access for this pathology.     

DeBakey IIIb aortic dissection originating in a distal aortic arch aneurysm.

This report presents a case of DeBakey IIIb aortic dissection originating in a distal aortic arch fusiform aneurysm. The atherosclerotic change of the aneurysm was mild and the letter "C"-shaped intimal flap was turned over to obstruct the true lumen blood flow. A four-branched woven Dacron vascular prosthesis was implanted in a double barrel fashion. Although this case was successfully managed, an emergent operation should have been conducted.     

Ruptured abdominal aortic aneurysm associated with a psoas abscess

A case of abdominal aortic aneurysm infected by Salmonella dublin is presented. Computed tomography (CT) revealed an abdominal aortic rupture associated with a psoas abscess. An axillo-femoral bypass was performed. The aneurysm and the psoas abscess were resected.     

Dissecting thoracoabdominal aortic aneurysm associated with an isolated right-sided aortic arch.

Although a right-sided aortic arch is not a rare anomaly, an aortic dissection involving an isolated right-sided aortic arch is extremely rare and remains a complicated entity for surgical therapy because of its anatomical characteristics. Previous reports that we have identified in English literature include only six surgical cases of aortic dissection involving a right-sided aortic arch. We report on a 75-year-old female who had a chronic thoracoabdominal aortic aneurysm following type B aortic dissection in a right-sided aortic arch. Graft replacement including reconstruction of Adamkiewicz artery and a celiac trunk was performed. The postoperative course was uneventful except for a prolonged ventilatory support. This case seems to be the first successful case of extended graft replacement for this pathology.     

Ruptured abdominal aortic aneurysm.

A total of 131 surgically treated ruptured abdominal aortic aneurysms have been reviewed. Factors affecting morbidity and mortality rates have been analyzed. In our experience very little improvement has occurred in the last 10 years and the question is raised whether a plateau has been reached in the management of this catastrophic disease. Patient selection is not considered to be the key to better results, since some operated patients inevitably die. Improved technique with better, more rapid control of blood loss, especially from venous tears, will continue to yield better results. Eighty-six nonoperative cases have been studied. Diagnostic accuracy is lower than it should be, often leading to delayed surgery or death.     

Single-stage surgery for distal aortic arch aneurysm and infrarenal abdominal aortic aneurysm through anterolateral approach.

A 58-year-old man with a distal aortic arch aneurysm (DAA) associated with an infrarenal abdominal aortic aneurysm (AAA) successfully underwent a single-stage replacement of the aneurysms. A left anterolateral thoracotomy was used for replacement of the DAA, which was performed using profound hypothermic circulatory arrest and continuous retrograde cerebral perfusion. An extraperitoneal approach in conjunction with a lateral abdominal incision was employed for replacement of the AAA. The combination of an anterolateral thoracotomy and a lateral abdominal incision is useful in combined surgery for DAA and AAA.     

Ruptured intracranial aneurysm associated with unruptured abdominal aortic aneurysm--case report

A 61-year-old male with hypertension presented with sudden onset of headache and nausea due to subarachnoid hemorrhage (SAH). He had two siblings with history of SAH due to ruptured intracranial aneurysms. Right carotid angiography on admission showed an anterior communicating artery aneurysm. At that time, the extracranial arteries were not examined. The aneurysm was clipped with no complications. A pulsating mass was palpable in the abdomen 37 days after the onset. Ultrasonography and computed tomography showed an abdominal aortic aneurysm with intraluminal thrombus, measuring 8 x 9 x 8 cm. Normal pressure hydrocephalus had already developed. The patient underwent elective abdominal aortic aneurysm resection before ventriculoperitoneal shunting. After shunting, he recovered fully. The present case indicates that unpredictable sudden enlargement of associated abdominal aortic aneurysm is possible in patients with ruptured intracranial aneurysms.     

Mycotic aneurysm of the distal aortic arch caused by Aspergillus.

We describe an unusual case of a thoracic aortic aneurysm caused by Aspergillus. A 70-year-old man underwent prednisolone and Ara-C treatments for a myelodysplastic syndrome. Blood examination revealed pancytopenia. Under these treatments, an aneurysm presented at the distal aortic arch. He underwent resection of the aneurysm with a graft repair covered by a pedicled omentum flap, followed by prolonged administration of micafungin and itraconazole for a mycotic aneurysm. The postoperative course was favorable without complications. Serum C-reactive protein became negative and he was discharged 2 months after the surgery. However, 4 months after the surgery, he died from worsening of the myelodysplastic syndrome. The prognosis for patients with mycotic aneurysms is poor due to their immunocompetent condition arising from underlying diseases. Therefore, in addition to prompt treatment with antifungal agents combined with surgical debridement, control of the underlying disease is essential for improving the outcome.     

Ruptured aortic arch aneurysm with hemorrhagic cardiac tamponade: report of a case

A 67-year-old female was sent into our hospital for ruptured thoracic aneurysm with hemorrhagic cardiac tamponade. Computed tomography (CT) showed pericardial effusion and ruptured aortic arch aneurysm. We performed urgent graft replacement of the aortic arch using selective cerebral perfusion under mild hypothermia. Postoperative course was uneventful.     

Ruptured aortic arch aneurysm with hemorrhagic cardiac tamponade; report of a case

The ruptured aortic arch aneurysm with cardiac tamponade is rare and has severely high mortality. We report a case of ruptured aortic arch aneurysm with cardiac tamponade. A 66-year-old man who had syncope attack was transferred to city hospital. Brain computed tomography (CT) showed no significant lesion and he admitted to our hospital for suspecting of aortic dissection. Chest CT showed ruptured aortic arch aneurysm and pericardial effusion. Emergent operation was done on the same day. It was found that the hematoma beneath the tunica adventitia existed at the distal arch and extended to the ascending aorta. Cardiac tamponade was caused by rupture of subadventitial hematoma in pericardial space. Aortic arch replacement was performed using selective cerebral perfusion under deep hypothermia. Postoperatively, he had no cerebral complication and was discharged uneventfully.     

Anesthetic management for distal aortic arch aneurysm stent grafting

A 76-year-old woman with thoracic aortic aneurysm involving distal aortic arch was scheduled for graft replacement from ascending to proximal aortic arch with endovascular stent graft to descending aorta. Surgical procedures were performed under median sternotomy with hypothermic systemic circulation arrest and selective cerebral perfusion. The stent graft composed of 30 mm Gianturco Z stent and 27.5 mm woven Dacron graft was introduced into the descending aorta under the guidance of transesophageal echocardiography (TEE) and fluoroscopy. Ascending and proximal aortic arch replacement was then performed with four branched woven Dacron graft. The aortic pathology was confirmed by TEE and the extent of the aneurysmal lesion was defined. TEE was also useful to find the dislodgement of the stent graft after deployment. This surgical technique, being less invasive than conventional thoracotomy, would be indicated for elderly patients with distal aortic arch aneurysm. TEE is the vital imaging technique for placement of the stent graft, as well as for intraoperative cardiac monitoring.     

Mycotic aneurysm of the distal aortic arch caused byAspergillus

We describe an unusual case of a thoracic aortic aneurysm caused byAspergillus. A 70-year-old man underwent prednisolone and Ara-C treatments for a myelodysplastic syndrome. Blood examination revealed pancytopenia. Under these treatments, an aneurysm presented at the distal aortic arch. He underwent resection of the aneurysm with a graft repair covered by a pedicled omentum flap, followed by prolonged administration of micafungin and itraconazole for a mycotic aneurysm. The postoperative course was favorable without complications. Serum C-reactive protein became negative and he was discharged 2 months after the surgery. However, 4 months after the surgery, he died from worsening of the myelodysplastic syndrome. The prognosis for patients with mycotic aneurysms is poor due to their immunocompetent condition arising from underlying diseases. Therefore, in addition to prompt treatment with antifungal agents combined with surgical debridement, control of the underlying disease is essential for improving the outcome. (Jpn J Thorac Cardiovasc Surg 2006; 54:160-163)     

Ruptured abdominal aortic aneurysm associated with an aorto-enteric fistula. A case report

A patient with a ruptured abdominal aortic aneurysm and a primary aortoduodenal fistula is reported on. Treatment included aneurysmectomy, suture of the duodenal fistula, closure of the proximal and distal abdominal aortic stumps, and construction of an axillobifemoral bypass. The postoperative course was complicated by spinal cord ischaemia and pataplegia, Gram-negative septicaemia, secondary intra-abdominal haemorrhage and multiple abscess formation.     

Endovascular stent-grafting through the aortic arch: an alternative approach for distal arch aortic aneurysm

BACKGROUND: Endovascular stent-grafting is an innovative procedure; we have developed a novel approach to treat distal arch aortic aneurysm through a small incision in the aortic arch. METHODS: Eight patients with thoracic aortic aneurysms were treated with an endovascular stent-graft that was introduced into the thoracic aorta through a small incision in the aortic arch. Of these patients, 7 had distal arch aortic aneurysms, and 1 had chronic aortic dissection of Stanford type B. Four of these patients had received concomitant coronary artery bypass grafting, and 1 patient had undergone tricuspid valvular annuloplasty. The stent-graft was introduced into the distal arch aorta and descending aorta through a small incision in the aortic arch, under selective cerebral perfusion and hypothermic circulatory arrest. RESULTS: The selective cerebral perfusion time ranged from 52 to 86 minutes (mean, 68 minutes) and the operating time from 289 to 422 minutes (mean, 318 minutes). There was no endoluminal leakage into the aneurysm. Seven patients survived and were discharged, but 1 patient suffered a cerebral infarction and died during the follow-up period. CONCLUSIONS: Placing an endovascular stent-graft through the aortic arch is an acceptable alternative treatment for distal arch aortic aneurysms.     

Ruptured aortic arch aneurysm: transposition of aortic arch branches after insertion of thoracic endovascular stent with extra-anatomic brain perfusion

Conventional surgical treatment of a ruptured aortic arch aneurysm is a challenging approach with a high rate of adverse outcomes. The midsternotomy can be complicated by total aortic disruption with often fatal massive hemorrhage. A preliminary cardiopulmonary bypass with peripheral cannulation and cooling is often preferred. Endovascular stents have been used in patients with thoraco-abdominal aneurysms, with good results. Its lone utilization for rupture of aortic arch aneurysm is not feasible because of the unavoidable occlusion of cerebral vessels' origins. A previous aorto-bicarotid bypass is mandatory and it requires the midsternotomy. Hence, we developed a combined technique. We performed a hybrid approach in a 74-year-old patient, affected by an aortic arch aneurysm, ruptured in its antero-inferior portion. First we ensured brain perfusion with a temporary surgical extra-anatomic (femoral-bicarotid) bypass. Then an endovascular stent graft was expanded from the distal portion of ascending aorta to the proximal one of the thoracic aorta, thus excluding the ruptured portion of the aortic arch. Then the patient underwent the definitive aorto-carotid bypass. This specific combined technique allows the complete treatment of a ruptured arch aneurysm, lowering the risks connected with sternothomic approach, mainly with previous cardiopulmonary bypass and deep hypothermic circulatory arrest.